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Breast oncology ?

Breast oncology is a branch of oncology focusing on the diagnosis, treatment, and management of breast cancer. Breast cancer is one of the most common cancers in women globally, but advancements in screening, diagnosis, and treatment have significantly improved outcomes.

Treatment Modalities

Incidence: Most common cancer among women worldwide.

Risk Factors:

  • Genetic predisposition (BRCA1/BRCA2 mutations).

  • Hormonal factors (e.g., early menarche, late menopause, nulliparity).

  • Lifestyle factors (e.g., alcohol consumption, obesity).

Screening and Diagnosis

Screening:

  • Mammography: Gold standard for early detection.

  • Ultrasound and MRI: Used in specific cases.

  • Breast self-exam and clinical breast exam.

Diagnostic Modalities:

  • Imaging:Mammogram, ultrasound, MRI.

  • Biopsy:Core needle biopsy, fine-needle aspiration (FNA), or excisional biopsy.

  • Molecular Profiling: ER/PR/HER2 status to guide treatment.

Pathology and Molecular Subtypes

Histologic Types:

  • Ductal carcinoma in situ (DCIS).

  • Invasive ductal carcinoma (IDC) – most common.

  • Lobular carcinoma.

Molecular Subtypes:

  • Luminal A: ER/PR positive, HER2 negative, low Ki-67.

  • Luminal B: ER/PR positive, HER2 positive or high Ki-67.

  • HER2-enriched: HER2 positive, ER/PR negative.

  • Triple-negative: ER/PR/HER2 negative.

Treatment Modalities

Surgery:

  • Breast-conserving surgery (BCS).

  • Mastectomy.

  • Sentinel lymph node biopsy or axillary dissection.

Radiation Therapy:

  • Whole-breast irradiation (WBI) after BCS.

  • Hypofractionated schedules gaining popularity.

  • Partial breast irradiation (PBI) and brachytherapy in select cases.

Systemic Therapy:

  • Chemotherapy:Based on tumor size, nodal status, and subtype.

  • Hormonal therapy:Tamoxifen, aromatase inhibitors for ER/PR-positive tumors.

  • Targeted therapy:Trastuzumab, pertuzumab for HER2-positive cancers.

  • Immunotherapy:Emerging for triple-negative cancers (e.g., PD-1/PD-L1 inhibitors).

  • Brachytherapy:High-dose-rate (HDR) interstitial or intracavitary brachytherapy for partial breast irradiation.

Radiation Therapy (RT)

Techniques:

  • External beam radiotherapy (EBRT): IMRT, VMAT, IGRT for precise dose delivery while sparing normal tissues.

  • Brachytherapy: Ideal for small, localized tumors, especially in the oral cavity or lip.

Indications:

  • Definitive RT for early-stage cancers (especially laryngeal, nasopharyngeal).

  • Adjuvant RT after surgery for high-risk features (positive margins, extracapsular spread).

  • Palliative RT for symptom control (e.g., pain, bleeding).

Dose:

  • Definitive: 66-70 Gy in 33-35 fractions.

  • Post-operative: 60-66 Gy in 30-33 fractions.

Advances in Breast Oncology

Genomic Testing: Oncotype DX, MammaPrint for recurrence risk assessment.

Minimally Invasive Techniques:Vacuum-assisted biopsy, oncoplastic surgery.

Radiotherapy Advances:Deep inspiration breath-hold (DIBH) for cardiac sparing.

The treatment modalities for breast cancer are determined by factors such as the stage, molecular subtype, patient comorbidities, and preferences. A multidisciplinary approach involving surgery, radiation therapy, systemic therapy, and supportive care is often employed.

Surgery

Types of Breast Surgery

Breast-Conserving Surgery (BCS):

  • Lumpectomy or wide local excision.

  • Often combined with adjuvant radiation to preserve breast tissue.

Mastectomy:

  • Simple mastectomy:Removal of the breast without axillary lymph nodes.

  • Modified radical mastectomy:Includes axillary lymph node dissection.

  • Skin-sparing or nipple-sparing mastectomy:Preserves more of the breast's appearance.

Reconstructive Surgery:

  • Immediate or delayed reconstruction using implants or autologous tissue.

Axillary Surgery:

  • Sentinel Lymph Node Biopsy (SLNB):For early-stage disease with clinically negative nodes.

  • Axillary Lymph Node Dissection (ALND):For node-positive disease or failed SLNB.

Radiation Therapy

Radiation therapy reduces local recurrence rates and improves survival in many cases.

Indications

  • Post-BCS for all stages.

  • Post-mastectomy for high-risk features (e.g., T3 tumors, ≥4 positive nodes).

  • Locally advanced or inoperable breast cancer as part of neoadjuvant therapy.

Techniques

Whole Breast Irradiation (WBI):

  • Conventional or hypofractionated (e.g., 40 Gy/15 fractions over 3 weeks).

Partial Breast Irradiation (PBI):

  • External beam, intraoperative radiotherapy (IORT), or brachytherapy.

Advanced Techniques:

  • Deep inspiration breath-hold (DIBH) to minimize cardiac dose.

  • Intensity-modulated radiotherapy (IMRT) for dose uniformity.

Brachytherapy:

  • Used in selected cases of early-stage breast cancer.

  • High-dose-rate (HDR) interstitial or intracavitary brachytherapy.

Systemic Therapy

Systemic therapy is tailored based on molecular subtypes, tumor size, and nodal involvement.

Chemotherapy:

  • Indicated for high-risk early-stage or advanced breast cancer.

Common regimens:

  • Anthracyclines (e.g., doxorubicin) and taxanes (e.g., paclitaxel).

  • CMF (cyclophosphamide, methotrexate, 5-fluorouracil) for specific cases.

  • Neoadjuvant chemotherapy: For downstaging tumors or enabling BCS.

Endocrine Therapy:

  • For hormone receptor-positive (ER/PR+) cancers.

  • Premenopausal: Tamoxifen for 5-10 years.

  • Postmenopausal: Aromatase inhibitors (e.g., anastrozole).

  • Ovarian suppression/ablation in premenopausal women with high-risk disease.

Targeted Therapy:

  • HER2-positive cancers:Trastuzumab and pertuzumab.

  • Antibody-drug conjugates: T-DM1 (trastuzumab emtansine).

Triple-negative cancers:

  • PARP inhibitors (e.g., olaparib) for BRCA-mutated cancers.

  • Immunotherapy: PD-1/PD-L1 inhibitors (e.g., atezolizumab).

Emerging Therapies:

  • CDK4/6 inhibitors (e.g., palbociclib) for advanced ER-positive, HER2-negative cancers.

  • mTOR inhibitors (e.g., everolimus).

Hormonal and Biological Therapy

Hormonal therapy is pivotal for ER/PR-positive tumors.

Ongoing research focuses on molecular targets, including PI3K inhibitors and other biomarkers.

Palliative Therapy

For metastatic breast cancer, the goal is symptom control and prolonging life.

Options include:

  • Palliative radiotherapy for bone or brain metastases.

  • Bisphosphonates or denosumab for bone health.

  • Endocrine and chemotherapy to manage systemic disease.

Multimodal Therapy

Treatment often combines

  • Surgery + Radiation (early-stage).

  • Neoadjuvant chemotherapy + Surgery + Radiation (locally advanced).

  • Systemic therapy alone for metastatic disease.

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